Eosinophilic esophagitis
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Eosinophilic Esophagitis . Case Presentation 35 year old man presented with intermittent upper esophageal dysphagia, mostly with solids for > 5 years. It had become progressively worse and he had problems swallowing “any solid food”. No weight loss. No heartburn symptoms.

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Case Presentation

35 year old man presented with intermittent upper esophageal dysphagia, mostly with solids for > 5 years.

It had become progressively worse and he had problems swallowing “any solid food”.

No weight loss. No heartburn symptoms.

No prior treatment, no current meds


EGD

Although no stricture was seen in the esophagus or the GE junction, moderate pressure was needed to advance to this point.

Multiple rings were seen intermittently throughout the esophagus.

The endoscopy could not be advanced beyond the GE junction

due to the floppy, tortuous esophagus.


As the scope was withdrawn a 3cm superficial mucosal tear was seen in the mid esophagus.

Michael B. Harper, M.D.


Michael B. Harper, M.D. was seen in the mid esophagus.


There was no blood loss. was seen in the mid esophagus.

Although the mucosa did not appear inflamed, it was friable and thin.

Michael B. Harper, M.D.


Michael B. Harper, M.D. was seen in the mid esophagus.


Multiple cold forceps biopsies were taken from the GE junction and middle third of the esophagus

avoiding the site of the mucosal injury


Impression
Impression junction and middle third of the esophagus

  • Friable mucosa, with superficial linear tear.

  • Eosinophilic esophigitis, Strongly suspected

Michael B. Harper, M.D.


Plan junction and middle third of the esophagus

  • Soft diet for 24 hours after EGD (due to mucosal injury)

  • Start esomeprazole 40gm/d

Michael B. Harper, M.D.


Pathology report
Pathology report junction and middle third of the esophagus

  • Both biopsies display esophageal squamous mucosa with acute basal cell hyperplasia

  • and increased eosinophilic inflammation with areas in excess of 30 eosinophils per high power field consistent with eosinophilic esophagitis.

  • A PAS-D stain performed on the mid esophageal biopsy showed no evidence of fungal microorganisms.

Michael B. Harper, M.D.


marked basal zone hyperplasia junction and middle third of the esophagus

Michael B. Harper, M.D.


large numbers of eosinophils junction and middle third of the esophagus

greater than 40 per high power field

Michael B. Harper, M.D.


Plan following path report
Plan following path report junction and middle third of the esophagus

  • Started fluticasone 220ucg bid, do not inhale, and rinse mouth with small amount of water

  • Changed to lansoprazole orally disintegrating tablet

    • dysphagia with capsule

  • Consult allergist for food allergy testing and elimination diet

Michael B. Harper, M.D.


Plan following path report1
Plan following path report junction and middle third of the esophagus

  • Plan repeat EGD

    • After 6 weeks of treatment

      with pediatric endoscope

    • To confirm stomach and duodenum not involved

  • TNE if further esophageal exams needed

Michael B. Harper, M.D.


The mucosa may appear normal junction and middle third of the esophagus

Multiple rings are a typical finding

Corrugation

"trachea-like"

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.


linear furrowing junction and middle third of the esophagus

ulceration and strictures

multiple whitish papules or granular exudates

Other finding seen with

eosinophilic esophagitis

Michael B. Harper, M.D.


Perforations are common junction and middle third of the esophagus

do not force the endoscope

avoid dilatation

or wait until after treatment

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.


Diagnosis is based on clinical presentation and finding eosinophils on bx

Number per HPF not agreed upon

>15-25 is typically used

Eosinophils can be caused by GERD

Best to biopsy after treatment with PPI for at least 4 weeks

Teaching points

with eosinophilic esophagitis

Michael B. Harper, M.D.